Policy not Politics: A Dialogue About the Health Insurance Exchange

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  • Because ACA passed it because a bridge
  • When employers are offered 50-60 take up regardless of size of firm
  • To be assessed by HHSIf the state exchange will not be operational, HHS will put a Federal Exchange in placePossibility of “conditional approval”
  • Think about people coming from MCHA or people coming who have not had any insurance for while – pent up deman
  • 49 States and the District of Columbia received Federal “Exchange Planning” grants (Alaska did not apply)As of January 2012, reports indicate that AK has undertaken exchange planning activities without any grant funding28 States and the District of Columbia have received Federal “Establishment” grantsGrants ranged from $1.6M (TN) to $64M (RI)*Minnesota received $4.6MMore Establishment grants will be awarded in mid-February
  • Massachusetts: Small-group and individual markets merged
  • I went out for 50 year old – no gender rating, individual market, no subsidy
  • Here you have the NCQA quality rating that you can click on to get more information – these all have 4 stars but there may be some difference within the report
  • Utah: Non-group market not eligible for exchange participation
  • Policy not Politics: A Dialogue About the Health Insurance Exchange

    1. 1. Health Insurance ExchangeLynn A. Blewett, Ph.D.Professor, Division of Health Policy and Management,University of Minnesota School of Public HealthDirector, State Health Access Data Assistance CenterFebruary 7, 2012Funded by a grant from the Robert Wood Johnson Foundation
    2. 2. Overview of Presentation • Overview of Health Reform • What is the Problem? • Exchange Basics • Exchange Timeline • Key Decisions for States • Current State Activity • Existing Exchange Examples • Recommended Readingwww.shadac.org 2
    3. 3. Brief Overview of Health Reform • Exchange is just One Component • Coverage Expansions • Insurance Reformwww.shadac.org 3
    4. 4. Exchange Indv Mandate <138% Medicaid 55-64 139-400% Reinsurance subsidies Dependent 139-200% Care Basic Health Small Coverage Plan (optional) Employer Tax Credit No pre- High Risk existing Pool condition exclusions Early No rating onMedicaid gender or Bridge to health No annual Reform: limits 2010 2014 Expanding Coverage
    5. 5. Covering the Cost of Expansion • Percent of costs covered by Federal Medicaid expansion purchasing in the exchange: Year Percent of Costs 2014-2016 100% 2017 95% 2018 94% 2019 93% 2020+ 90%www.shadac.org 5
    6. 6. Coverage Expansion Categories Medicaid Premium Subsidy Expansion 138 % 139-400% Potential Health Benefit Plan 138-200% Medicaid Subsidy $31,089 $46,100 $92,200 Family Family Family of Of Four Of Four Four 0 100 200 300 400 500 2012 Federal Poverty Guideline for a family of four = $23,050* *Refers to the 48 contiguous states and the District of Columbia. The poverty guideline for Alaskawww.shadac.org is $28,820 for a family of four, and for Hawaii the guideline is $26,510. 6
    7. 7. Individual Mandate - 2014 • Individuals are required to maintain minimum essential coverage for themselves and their dependents. • Those who do not meet the mandate will be required to pay a penalty for each month of noncompliance: Average annual penalty will be $674 for average US citizenwww.shadac.org 7
    8. 8. Exemptions to the Individual Mandate • Financial hardship • Religious objections • American Indians and Alaska Natives • Incarcerated individuals • Those for whom the lowest cost plan option exceeds 8% of income, and • Those whose income is below the tax filing threshold And the Undocumentedwww.shadac.org 8
    9. 9. What policy problem is the Health Insurance Exchange trying to solve?• 50 million uninsured • Increase access to increase access to affordable coverage• Erosion of Employer • Increase offerings for Sponsored Insurance small employers• Unaffordable health • Provide tax credits to insurance premiums reduce premiums for• Carriers underwriting eligible indv people out of private • Organize market into market larger risk pool• Lack of consumer info • Organize/present plan comparisonswww.shadac.org 9
    10. 10. Health Insurance Coverage (2009) Type of Coverage for Minnesotans Age 0-64 Uninsured 10.1% Public Coverage 14.0% Non-Group Coverage 7.6% Employer- Sponsored Coverage 68.3%www.shadac.org Source: 2010 American Community Survey 10
    11. 11. Offer Rate of Private Employer ESI by Firm Size, 2009/10 Minnesota Offer (of establishments) 120% 100% 80% 60% 40% 20% 0% <10 10-24 25-99 100-999 1000+ Source: 2009, 2010 MEPS-IC, Table IIA2www.shadac.org 11
    12. 12. Take-up Rate of Private Employer ESI by Firm Size, 2009/10 Minnesota Take-up (of employees at establishments) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% <10 10-24 25-99 100-999 1000+ Source: 2009, 2010 MEPS-IC, Table IIB3B2www.shadac.org 12
    13. 13. Percent with Employer Sponsored Insurance (Age 19-64) 1999 to 2009 Minnesota 100 90 80.6% 80 70.7% 70 60 50 40 30 20 10 0 1999/2000 2008/2009www.shadac.org Source: 2000, 2001, 2009 CPS SHADAC-Enhanced 13
    14. 14. Single and Family Premiums, Minnesota $14,000 $11,905 $12,000 $10,000 $8,000 $6,587 $6,000 $4,516 $4,000 $2,455 $2,000 $- 1999/2000 2008/2009 1999/2000 2008/2009 Single Familywww.shadac.org Source: 1999/2000, 2008/2009 MEPS-IC 14
    15. 15. Exchange Basics • What is an Exchange under the ACA? – A web-based marketplace that organizes information about all available health insurance coverage options in a standardized format that allows comparison across plans with respect to premiums, cost-sharing, coverage and quality ratings – Consumers can select and enroll in coverage through the Exchange – If a consumer is identified as Medicaid-eligible, he/she can enroll in Medicaid through the Exchange or potentially quality for premium subsidy through the form of a tax creditwww.shadac.org 15
    16. 16. Plans Offered through the Exchanges • All plans offered through the Exchange must fall into one of four categories based on actuarial value • Plans within each of these four options will be similar – so the consumer will be comparing apples to applies • Plans may offer catastrophic coverage available only for young adults (under 30) • All plans offered through the Exchange must offer at least one silver and one gold plan • All plans must cover the Essential Benefits Packagewww.shadac.org 16
    17. 17. Examples of Benefit Designs for Various Actuarial Values Plan Actuarial Deductible Out-of- Coinsurance Value Pocket Maximum Platinum 90% $250 $2000 15% Gold 80% $500 $4000 35% Silver 70% $1500 $5000 45% Bronze 60% $2000 $7500 50% This example accounts for anticipated higher utilization as the expected behavioral response to lower cost-sharing—based on national average experience Source: http://publications.milliman.com/publications/healthreform/pdfs/health-exchange-impact- plan.pdfwww.shadac.org 17
    18. 18. Key State Decisions That Will Affect Premiums Have single state exchange, multi-state exchange, multiple exchanges Should within state ? exchange serve Limit small business to (<50) as market participation in organizer or exchange? active purchaser? These Merge decisions How will the individual and group will affect state fund the insurance exchange? markets? premiumswww.shadac.org 18
    19. 19. Additional Information • Timeline • Risk Adjustment • Reinsurance • Essential Benefitswww.shadac.org 19
    20. 20. Significant Dates for Exchange Implementation • January 1, 2013: States must demonstrate that exchanges can be operational by January 1, 2014 • Jan 2013: Exchanges undergo testing • Oct 2013: Open Enrollment begins • Jan 2014: States begin to offer coverage through the exchanges • Jan 2015: Exchange must be financially Self- Sufficientwww.shadac.org 20
    21. 21. Help with potential enrollment of High-Risk Enrollees • Risk Adjustment for Individual and Small group market – Adjusting premiums to reflect risk profile of the insured group. Zero-sum game. Plans with individuals with higher risk will receive $$ adjustments to reflect higher costs, those with lower risk profile may have reductions to premiums • Temporary Reinsurance Pool – Individual market Only – Corridors set by HHS – “Insuring the insurers” up to a pointwww.shadac.org 21
    22. 22. Risk Adjustment • Federal Risk Adjustment model to be released by October 2012 • States that want an alternative model must: – Submit model for approval by Nov 2012 – Develop own model or adjust federal model • Feds will turn around approval or suggestions for change by January 2012www.shadac.org 22
    23. 23. State Risk Adjustment Decisions • Prospective vs. concurrent model • Existing or home-grown model • Include pharmacy or not • Data fields to be used (include comorbidities?) • Rating variables and rating integration • Geographic area adjustments • How to score members with little experience • Role of all-payers claim data basewww.shadac.org 23
    24. 24. Temporary Reinsurance Pool - 2014 1) Each state establish a temporary 3-year reinsurance pool for the individual market, and 2) HHS establish will administer temporary risk corridors for payments to qualified health plans. 3) The formula for payments provides that aggregate amounts will total - $10 billion in 2014, - $6 billion in 2015, - $4 billion in 2016www.shadac.org 24
    25. 25. Essential Health Benefits (EHBs) • Set of services that must be included in health plans offered both in and outside of the exchange. • EHBs must include items and services in these 10 categories: – Ambulatory patient services – Emergency services – Hospitalization – Maternity and newborn care – Mental health and substance use disorder services, including behavioral health treatment – Prescription drugs – Rehabilitative and habilitative services and devices – Laboratory services – Preventive and wellness services and chronic disease management, and – Pediatric services, including oral and vision carewww.shadac.org
    26. 26. Flexibility for State Essential Health Benefits • “Benchmark approach” – each state to select a benchmark plan that reflects the scope of services offered by a typical employer plan in the state • If a state don’t choose a benchmark plan, HHS will propose that the default benchmark be the small group plan with the largest enrollment in the statewww.shadac.org
    27. 27. Options for State Benchmark Plan 1. One of the three largest small group plans in the state (by enrollment); 2. One of the three largest state employee health plans; 2. One of the three largest federal employee health plan options by enrollment; 3. The largest HMO plan offered in the state’s commercial market by enrollment.www.shadac.org 27
    28. 28. Other State Activity • 28 states doing something • MA example of existing exchange • Utah examplewww.shadac.org 28
    29. 29. State Activity on Health Insurance Exchangewww.shadac.org Source: http://www.ncsl.org/issues-research/health/state-actions-to-implement-the-he 29
    30. 30. Existing Exchanges: Massachusetts • Massachusetts: Two exchanges under the umbrella “Health Connector” exchange – Commonwealth Care: Exchange for subsidy-eligible individuals (up to 300% FPL) • Participation:159,000 members – Commonwealth Choice: Combined exchange for small-group and unsubsidized non-group insurance • Participation: 41,000 members – Active purchaser model – State collects a portion of premiums for products sold through the Connector to fund its operation •www.shadac.org Source: Massachusetts Health Care Reform - Facts and Figures: http://bit.ly/zjsbft 30
    31. 31. www.shadac.org 31
    32. 32. www.shadac.org 32
    33. 33. www.shadac.org 33
    34. 34. www.shadac.org 34
    35. 35. www.shadac.org 35
    36. 36. www.shadac.org 36
    37. 37. www.shadac.org
    38. 38. Existing Exchanges: Utah • Utah: One exchange – Utah Health Exchange: Single state exchange through which both small and large employers can make a defined contribution toward health insurance • No subsidies • Focus on transparency, consumer choice, and employer access to defined contribution market – Participation: 225 employer groups; 5,513 covered lives – Market organizer model – Funded by $650K annual allotment from the State Source: Utah Health Exchange – Dashboard:www.shadac.org http://www.exchange.utah.gov/images/stories/UHE_Dashboard_Jan_2012.pdf 38
    39. 39. Utah Health Exchange – An Introduction Source: http://www.exchange.utah.gov/www.shadac.org 39
    40. 40. A few more things about Minnesota • Jonathan Gruber modeling findings • Exchange Advisory Board making progress • MCHAwww.shadac.org 40
    41. 41. Gruber’s Estimate of Size of Exchange Individuals with/in Size of population Enrollment 1. Premium Subsidies 390,000 390,000 (138-400% FPL) 2. >400% FPL 130,000 70,000 (no subsidy) 3. Firms <50 receiving 70,000 70,000 Tax Credit 4. Firms <50 not 380,000 95,000 receiving Tax Credit 5. Firms 50-99 100,000 25,000 PRIVATE 650,000 6. Public Programs 500,000 500,000 TOTAL 1,150,000www.shadac.org Note: with no BHP, Jonathan Gruber MN presentation; 11-17-2011 41
    42. 42. Additional Gruber Findings • Premium changes in Minnesota’s individual and small group market range from -7% to +18% • Carrier who aggressively underwrite today will experience greater premium disruptions • Carries who moderately underwrite will experience less premiums Jonathan Gruber MN presentation; 11-17-2011www.shadac.org 42
    43. 43. Governor Adopted Exchange Board Recommendations • Things are moving… • Keeping a level playing field between marketplaces inside and outside the exchange; • Structuring provisions to encourage innovation and competition; • Stimulating participation by small employers; • Pursuing a state-level risk adjustment model. Still need to think about the 28,000 individuals enrolled in MCHA – (another talk..) MN House information service, Jan 30,2012www.shadac.org 43
    44. 44. Remember the problem and the target population… • Health Insurance Exchange is one part of health reform • Focus in on individual and small employer market – target population – Creating options for affordable coverage – Providing conduit for premium subsidy – Organizing information for easy selection • Exchange can go forward without the mandatewww.shadac.org 44
    45. 45. Recommended Reading Sonier, Julie and Patrick Holland. November 2010. “Health Insurance Exchanges: How Economic and Financial Modeling can Support State Implementation.” AcademyHealth-State Coverage Initiatives/SHADAC Issue Brief. http://www.shadac.org/files/shadac/publications/Brief_ExchangeModels_Nov201 0.pdf State Health Access Data Assistance Center. October 2010. “Health Insurance Exchanges: Implementation and Data Considerations for States and Existing Models for Comparison.” Issue Brief. http://www.shadac.org/files/shadac/publications/IssueBrief23.pdf State Health Reform Assistance Network. Risk Adjustment and Reinsurance: A Work Plan for State Officials Prepared by Wakely Consulting Group. December 2011 http://www.rwjf.org/files/research/73728.wakely.reinsurance.12.12.11.pdfwww.shadac.org 45
    46. 46. Contact information Lynn Blewett, blewe001@umn.edu State Health Access Data Assistance Center (SHADAC) blewe001@umn.edu 612-624-4802 ©2002-2009 Regents of the University of Minnesota. All rights reserved.www.shadac.org The University of Minnesota is an Equal Opportunity Employer 46

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